A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?
Monitor oxygen saturation (SpO2) via continuous pulse oximetry.
Observe neck for jugular vein distention.
Notify healthcare provider to prepare for pericardiocentesis.
Assess for paradoxical blood pressure.
The Correct Answer is C
A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.
B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.
C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.
D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Focusing on small achievable tasks helps to build a sense of accomplishment and reduce anxiety by breaking down overwhelming problems into manageable steps.
B. Analyzing past hurts may be useful in therapy, but for immediate coping, focusing on small tasks is more practical.
C. Relaxing and reducing effort might lead to avoidance rather than addressing anxiety.
D. Ventilating emotions is important but focusing on small tasks is more directly actionable for coping with anxiety and improving daily functioning.
Correct Answer is B
Explanation
A. Mixing the dose with food is not recommended as it might affect the absorption of the medication and does not address the immediate situation.
B. Withholding the dose is appropriate because it is uncertain how much of the medication was absorbed. Administering another dose could lead to toxicity.
C. Giving another dose without knowing how much was absorbed could cause an overdose.
D. Administering a half dose now is not recommended because the exact amount absorbed is unknown, risking either underdose or overdose.
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